Provider Demographics
NPI:1518928167
Name:THEAGENE, SAMUEL MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:MICHAEL
Last Name:THEAGENE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22422 MERRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2023
Mailing Address - Country:US
Mailing Address - Phone:347-270-8353
Mailing Address - Fax:347-826-1917
Practice Address - Street 1:22422 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:LAURELTON
Practice Address - State:NY
Practice Address - Zip Code:11413-2023
Practice Address - Country:US
Practice Address - Phone:347-270-8353
Practice Address - Fax:347-826-1917
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY194218208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400043923OtherPTAN
TX135761803Medicaid
TX135761803Medicaid
TXF92342Medicare UPIN